Enablement Approaches in Mental Health

[Pages:24]Enablement Approaches in Mental Health

A rapid review of existing evidence on Enablement

October 2016 Darren Vella, Dorothy Newton, Olivia Carmichael, Jana Alpaslan

Overview

Introduction:

The purpose of the Rapid Review was to explore available literature on `enablement' and identify if this approach has been found to shift settings of care, improve outcomes and create cost savings within the system. The search also aimed to identify if this effect is observed either in new patients coming into the mental health system versus those who have been long term users of the mental health system.

Due to the concept of enablement being a relatively new concept in healthcare the search conducted by the Rapid Review team on the topic was inconclusive. The research identified that `Enablement' has been written about from a broader health perspective (Huden et al, 2011) but no empirical evidence was identified within mental health.

The following review includes seven case studies and findings of its literature review.

Methodology:

The rapid review used a mixed methodology combining qualitative and quantitative approaches to capture a broad range of examples. The first stage used desktop research via academic resources such as the King's Fund, Birkbeck Library, EBSCOhost, JStor and Google Scholar.

The search initially sought to ascertain the evidence base for `Enablement' and `mental health' which did not yield comprehensive results specifically in Mental Health. However, conceptual articles on `enablement' in health care interventions were identified as well as some academic literature on specific instruments used to measure enablement which have been included in the rapid review.

Search terms were refined to eliminate unnecessary articles, and studies were identified that specified implementation of an enablement programme or aspects of "Live, Love, Do". Other terminology such as `goal oriented interventions' was also used, and articles addressing the financial implications and/or outcomes were prioritised.

Our search results identified a number of existing enablement schemes which are included in the findings, as well as the contact details for

reference. Due to the nature of a rapid review, a systemic method was not used, nor was there an in-depth analysis of the results. Instead, the

review aims to provide a summary of some key examples available.

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Existing enablement programmes and approaches

Summary of existing enablement programme and approaches

The desktop review identified that most enablement programmes and approaches which are typically run by Local Authorities have a distinct focus on short term work that is undertaken with the elderly and these schemes typically do not include mental health patients as part of their population cohort. Many of the programmes identified use terms such as enablement and reablement interchangeably with a clear focus on admission avoidance and regaining confidence at home. The schemes identified below differ from many existing schemes as they either have a specific focus on Mental Health. These examples are included as a reference.

Organisation Description and Notes

Link

Hertfordshire Care Choices

Mind Islington

Hertfordshire enablement service, run in partnership with Goldsborough Homecare aims to deliver benefits to older people with physical and/or mental health problems by helping people to live as independently as possible, preferably in their own home. This could be achieved through home care, home adaptations, Telecare or with information and advice about the range of support services available. Enablement beds in community settings are provided for anyone who might not be able to manage living at home.

The service is focused on prevention and early intervention to ensure that people are assisted to maintain their independence and improve the quality of their lives. The service gives people the opportunities to develop personal goals relating to their health and quality of life. Offers an 8-week focused intervention which can include a volunteer to help the service user reach their desired goals.

Scheme Website: Link

Scheme Website: Link Contact Details: ossi.ron@.uk Service Description:

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Case Studies

Transforming London's health and care together

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Case Study 1: Recovery and Economics

Background:

Personal recovery as an approach to psychiatric rehabilitation is attracting growing attention in many health systems. It emphasises the attainment of personal goals, meaning and control in life, rather than symptom alleviation. This paper examined the economic evidence available in relation to a set of interventions that could be seen to be consistent with a recovery-focused approach. These included peer support, selfmanagement, supported employment, welfare & debt advice, joint crisis plans & advance directives, supported housing, physical health promotion, personal budgets, anti-stigma campaigns and recovery colleges. This paper's approach ? which was not built on systemic review ? was to identify some interventions (services, strategies or actions) which could be seen as consistent with the personal recovery approach and then address whether there is evidence for an economic case for them. This paper focuses primarily on mental health & recovery in England.

The Evidence Found:

Peer support approaches ? currently little economic evidence to support it ? 2 UK studies cited evidenced decrease in costs but neither study methodologically strong. Similarly, little economic evidence found to support self-management (improving one's ability to manage symptoms and treatment). Employment ? much evidence available to support the economic case for supported employment. In particular, the Individual Placement and Support (IPS) system has been demonstrated in a 6-city EU study to be strongly costeffective. Physical health promotion is an important aspect of recovery, with supportive economic evidence for smoking cessation and weight management programmes. Recovery colleges ? these are now established in a few countries but were found to not yet have an evidence base. Anti-stigma campaigns in England & Scotland have demonstrated modest but significant positive impacts on population-level attitudes. They were low cost and also potentially cost-effective through encouraging people to use appropriate services. Joint crisis plans & advance directives ? although attracting growing

interest, no corresponding economic evidence to support them could be found.

Outcomes against Rapid Review Questions:

1. Little economic evidence to date to support peer-support or self-management approaches. Much financial evidence available to support the use of supported employment, in particular the Individual Placement & Support System. No evidence base yet re financial benefits of Recovery Colleges. Potential cost benefit of anti-stigma programmes which are also noted as being low-cost to implement. No evidence as yet to support joint crisis plans and advance directives. Overall, the available economic evidence is patchy and sometimes methodologically weak, but overall broadly supportive of a recovery-focused approach

2. This work was economics-focused and did not explore other aspects of shifting care to more community-based systems 3. This work did not specifically focus on new patient presentations versus individuals already known to mental health services

Summary:

The authors described their findings as `a loose collection of fragments of evidence drawn from a heterogeneous set of studies of variable quality.' The

available economic evidence is patchy and sometimes methodologically weak, but overall broadly supportive of a recovery-focused approach.

Interventions aiming to empower people with mental health issues, helping them to pursue goals which they value as important to themselves, do not

appear to increase costs: in many cases they lead to a more cost-effective utilisation of resources. At the same time, developments such as recovery

colleges are moving ahead quite rapidly, but without yet much evidence on their effectiveness or economic implications.

References: Knapp, M., McDaid, D. and Park, A. (2015). Recovery and Economics. Die Psychiatrie, 3.

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Case Study 2: Commissioning what works: The economic and financial case for supported employment

Background:

A briefing document aimed primarily at those responsible for commissioning employment-related and other services for people with severe mental health problems. The paper is part of a series being produced by Sainsbury Centre for Mental Health for an initiative to promote the systematic implementation of Individual Placement and Support (IPS), a form of employment support which helps people with severe and enduring mental health problems into competitive jobs. It is an analysis of the economic and financial case for IPS.

IPS is designed to help people with severe mental health problems who are not currently in work. In line with this focus, the analysis set out in the paper does not deal with the support needs of people whose mental health problems are mild to moderate or with the important but separate issue of helping those who are already in work to retain their jobs.

Summary:

There was abundant evidence found to show that IPS is more effective than any other form of vocational support in helping people get a job. Other evidence reviewed in the paper indicated that it is affordable and good value for money. IPS was seen to cost no more than traditional vocational services such as sheltered work. There was also strong evidence to show IPS as more effective than any other form of vocational support in helping people get jobs.

The Evidence Found:

Up to 90% of mental health service users want to work yet annual surveys of service users carried out by the Healthcare Commission (now the Care Quality Commission) show that the number in employment is only about 20%, a figure which has remained broadly constant for several years. IPS is seen to help more people find jobs, raises incomes and improves quality of life. Increasing evidence to suggest that it can lead to long-term expenditure savings as those who find work make reduced use of mental health services. The cost of implementing IPS at the level of provision recommended in government commissioning guidance on vocational services is estimated at around ?67 million a year nationally. In comparison, current spending on day and employment services is around ?184 million a year. This implies IPS could readily be established within existing provision by diverting resources from less effective services.

Outcomes against Rapid Review Questions:

1. Increasing evidence to suggest that IPS can lead to long-term expenditure savings as those who find work make reduced use of mental health services.

2. Tangible shift evident in this work towards individuals gaining employment and reduce use of mental health services (not specified whether primary or secondary care level)

3. This work does not specify `new' versus `existing' service users

References: Sainsbury Centre Centre for Mental Health.

for

Mental

Health,

(2009).

Commissioning

what

works:

The

economic

and

financial

case

for

supported

employment.

London:

Sainsbury6

Case Study 3: Five-Year Experience of first episode non-affective psychosis in open dialogue approach: Treatment Principles, follow up outcomes and two case studies

Background:

Since the early 1980s in Finnish Western Lapland, a new innovation was introduced within the needs-adapted approach of patient care: the Open Dialogue (OD) approach. The Open Dialogue family and network approach aims to treat psychotic patients in their homes. The treatment involves the patient's social network and starts within 24 hours of the first contact. The idea behind OD is provision of psychotherapeutic treatment for all patients within their own personal support systems. This is done by generating dialogue within the treatment system and families and involves mobile crisis intervention teams, patients and their social networks in meetings. A key component of the OD approach is that all clinical staff (both hospital and community-based) could be called upon to participate in these teams according to specific needs. In a crisis, regardless of diagnosis, the same procedure is followed in all cases. The team usually comprises 2-3 staff members (a psychiatrist from the crisis team, a psychologist from the local mental health outpatient clinic and a nurse from the hospital ward). The team formed takes charge of the entire treatment, regardless of whether or not the patient is hospitalised at any stage.

The Evidence Found:

The study was not planned as a randomised trial to evaluate a treatment method but rather was a descriptive study of the entire treatment system in a single catchment area.

The study examined 2 patient cohorts ? API group (before OD approach in fullphase) & ODAP (patients seen during full-phase of OD provision). The API period can be described as an earlier phase in the development of the ODAP period. This was a historical comparison on 5-year follow-ups. In the ODAP group the mean duration of psychosis declined to 3.3 months. This group also had fewer hospital days and fewer family meetings. However, there were no significant differences emerging in the 5-year treatment outcomes.

Outcomes against Rapid Review Questions:

1. Potential, although untested, cost-efficiency of OD approach (fewer hospital days, more emphasis on community-based treatment) 2. Evidence of focus of care shifting from secondary hospital-based to community with transfer of staff to fill need in community setting 3. This study looked at new patients (first onset non-affective psychosis), not individuals already known to mental health services

Summary:

OD demonstrated (in Western Lapland) to potentially reduce hospital days and number of family meetings in patients with first presentation psychosis. The authors found OD to be an inexpensive approach. Building up the OD system meant moving hospital staff to crisis intervention work in the outpatient setting. There has been no analysis of the cost-effectiveness of OD formally conducted.

References: Seikkula, J., Aaltonen, J., Alakare, B., Haarakangas, K., Ker?nen, J. and Lehtinen, K. (2006). Five-year experience of first-episode nonaffective psychosis

in open-dialogue approach: Treatment principles, follow-up outcomes, and two case studies. Psychotherapy Research, 16(2), pp.214-228.

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Case Study 4: From Ethnography to Randomised Controlled Trial: An Innovative Approach to Developing Complex Social Interventions

Background:

This article discusses an innovative approach to developing a social intervention ? the Connecting People Intervention ? which is planned to be amenable to evaluation in a randomised controlled trial. It is a prospective paper which describes the studies planned & currently underway rather than initial/final outcomes or data analysis. The intervention aims to help people recovering from an episode of psychosis to connect, or reconnect, with other people. It is envisaged that by ensuring the intervention is grounded in the lived experience of workers and service users it will be more amenable to implementation in routine practice, and produce better outcomes. The intervention is an ethnographic approach combined with current good practice in developing complex interventions in social work & social care. The work is based on the premise that social factors are prominent in the aetiology of psychosis. Those with psychosis face social exclusion, have restricted social networks and limited access to social capital. Social capital is being increasingly recognised as important for health and well-being. The author believes better understanding of social capital could assist in the development of new social interventions which may support an individual's recovery.

The Evidence Found:

Early indications from current activities in the Connecting People Study show that social care does not routinely draw upon a social capital paradigm and that social capital enhancement is not the current primary objective of social care or social work. The social capital intervention will be articulated in the form of an intervention manual as its end product. Of note, the author flags up the potential cost limitations of using ethnographic studies to develop the

intervention in different countries or cultural contexts.

Outcomes against Rapid Review Questions:

1. No financial costings data in this work. However, author notes caution when considering the potential cost of ethnographic studies underpinning the Connecting People approach

2. Emphasis on social capital and connections/relationships but no data to support this to date

3. Study focused only on patients with psychotic illness but not other forms of mental health difficulty

Summary:

On-going use of ethnographic study to inform potential new care approaches to those with psychotic illness, based on the importance of social capital in health and well-being. No outcome data yet available. Highlights the growing interest in social capital and relationships being key to mental wellbeing & recovery.

References: Webber M. (2014) From ethnography to randomized controlled trial: an innovative approach to developing complex social interventions.

Journal of Evidence-Based Social Work 11(1-2), 173-182.

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